SOME STORIES IN THE HISTORY OF MEDICINE
Lecture 2: Contagion, Infection, Antisepsis
Adam Blatner, M.D.
(This six-lecture series is part of Senior University Georgetown’s Winter-Spring 2009 session.)
You can also click on the following links:
1. The first lecture was an introduction and some history of the microscope, laying the foundation for the other lectures.on the background
Also, three supplements, which you can click on to link to related webpages:
A. A very brief overview of the history of medicine. (pre-history to the Renaissance) (just to get you oriented)
B. Further Overview to modern times.
C. A further history of microscopy.
Then: (To be posted as I prepare and give these lectures: )
(Lecture 2 is here on this present webpage). 3: The Early
History of Immunology ; 4:
The Discovery of
5: Recognizing Nutritional Deficiencies ; 6: Hygiene:
Sanitation, Hookworm, Dental Floss, & Summary
(First Posted February 2, 2009)
We'll start with a quote that appeared in an editorial in the 1801 edition of the publication, The Medical and Physical Journal (London, Volume 5, page 505)
The most important discoveries, when familiarized to the
mind, are contemplated with indifference. Who now wonders at the
discovery of America, or the circulation of the blood?
There is, however, a period between the conception of a discovery and
its mature birth, fraught with more pangs than war or women know; and
there is no light, in which the human mind can be viewed, more
interesting than during this anxious period.
Though a bit overblown with the kind of intellectual language style
then prevalent, this quote does suggest that even then thoughtful
people realized the complexities of discovery and the development
of knowledge. You may keep this in mind as you follow the rest of the
There are many people involved in the story of the recognition of germs
and the fight against infection, but for purposes of time and space,
this presentation focuses on just a few of the better-known figures
and, even then, just the highlights of their extensive stories. More
1.Ignac Semmelweiss, working in the 1840s and 1850s, in Vienna.
2. Oliver Wendell Holmes, Sr., working in Boston and its environs at the same time.
3. Louis Pasteur in France, whose major contributions happened between 1840 through 1890.
4. Joseph Lister, in Scotland, then England, working in the later 1850s through the 1880s and beyond.
5. Robert Koch... and just touching on some other pioneers in bacteriology and a-septic surgery.
How Relatively Recent It All IsWho among you are or know people who
have achieved grandparenthood? Good. In fact, four generations can
happen in a single lifetime. Now consider that your parents were
conceivably born with great-grandparents who grew up in a world where
an operation was an occasion for near-unbearable agony, and most wounds
became infectious. The reason there were so many amputations in the
civil war and other wars fought in and before the mid-nineteenth
century was that wounds became infected, frequently gangrenous, many
died from general infection, and the only thing you could do would be
to amputate the limb well above any gangrene. Yuk.
So the point is not to take the developments we’re talking about for granted!
The Development of Knowledge
In the last lecture I presented the following spectrum of knowledge, from the unknown to the known:
- What can never be known by the human mind
- What may well be discovered someday
- What only a very few people know---but most don't
- What some think they know, but they're mistaken
- What some partly know, because they have begun to put together the clues correctly
- What some know, but most others don't yet believe them
- What ideas have now been accepted by the major authorities in a given field, but not yet much known by the general population
- What has become familiar knowledge to parts of the population but is still unfamiliar or even a bit shocking to many others
- What has become commonly accepted by almost everyone in a culture
In a way this restates the quote at the beginning: We’re dealing
with the field of discovery and the dissemination of that knowledge, along with the
politics and technical difficulties of moving between what may be
discovered and getting it accepted and widely applied..
Breaking With Tradition
has been a gradient of status that has been associated with knowledge.
Part of this is associated with the technology of writing and the
authority that literacy conferred: If it was in a book it seemed as if
it must be true. Ignorance was so pervasive and life so
mysterious that anyone confident enough to write it up tended to be
believed. (We still need to work a bit to disconnect from this, to
question what is in print or on the internet.) Of course, political and
religious authority exploited this and made it official; as a result,
it was explicitly or implicitly taboo to doubt. The abdication of
favor of mindless obedience became a virtue. The difference between
respect and passive acceptance is still unclear for many. So, in
medicine, too, for many years, it was assumed that the
ancestors, the ancient scholars, really had an in with the truth. I
think that during the dark ages preceding the Renaissance people had
lost the spirit and techniques for inquiry and exploration, so that
reliance was a fall-back coping response.
in this sense, was also part of this tradition, relying primarily on
the writings of Galen around 140 CE and his dissections of
animals---because dissection of humans was religiously taboo. For the
next twelve hundred years and more, his writings were authoritative,
and the occasional anatomy was done as a scholarly
exercise was explained to the guests according to the established
texts. In the picture to the right, created in the mid-1400s,
the “Doctor” reading a traditional book
about what Galen said, while lowly and
ignorant technicians held up whatever the doctor told them to.
A new age was beginning. The growth of trade in the wake of the
Crusades also opened up a trade in manuscripts, and it turned out that
many of the ancient texts had been preserved first in the Byzantine
empire, then by the Islamic countries, and as well, there had been
advances in chemistry, mathematics, astronomy, and medicine in those
regions even as Western Europe was mired in the Dark Ages. The new age
was considered a re-birth of learning---and another word for re-birth
is Renaissance---a term given a feew centuries later by historians.
On one hand, the ancient texts were indeed respected, but there were
enough new bits and other things---like printing and the growth of
literacy---so that along with this came an interest in questioning
knowledge that was asserted to be true simply because it was old and
established. Nevertheless, to put this into a little perspective,
starting in around the
16th century and advancing well into the 19th, this questioning of
authority was only done by a relatively few
educated people around Euruope. The real subversion was a shift in the
way people thought about truth: Reason
was slowly emerging as the criteria for truth, instead of blind
acceptance of tradition. It should be noted, though, that the dominant
culture remained authority-bound and evocative of a corresponding
tendency towards mindless obedience—a practice that continued well into
our own lifetimes.
In the mid-1500s,
Andreas Vesalius and then others did their own dissections and found
out that frequently the authorities were mistaken. This was one of the
revolutions in the history of medicine.
However, Vesalius was a maverick---he wasn't really typical of
the proper way to be a scholar and educated man. Tradition dies hard.
The old way still dominated
medical training three hundred years later.
In this caricature by
Hogarth, the doctor still wouldn’t dream of getting down and getting
his hands dirty. So Vesalius was by no means typical—a maverick.
the story forward to the 1700s, while anatomy revealed how the
human body is constructed, something else was also revealed:
Abnormalities of various types were discovered, and gradually it became
apparent that these might be correlated with the patient's symptoms and
signs before they died. Indeed, the idea of doing a dissection to find
out why a person died---now called an autopsy---was stilll new.
Doctors had begun to notice things like
the fact that patients who had shown signs of yellow jaundice
before they died often showed growths in their livers or other
disturbances of nearby organs---such as stones in their gallbladder or
bile ducts. Or a patient who had stopped producing urine and shown
other signs often, on autopsy, was found to have abnormally shrunken
kidneys or other distortions of normal anatomy.
While it is recognized today as an "obvious" truth that disease was
often associated with specific organs, that was quite new back then.
One more notable pioneer in this new development was Giovanni Morgagni,
in Italy. For around twenty years, in the mid 1700s, when George
Washington was still a boy, Morgagni worked on research and writing,
and when he published, it shifted the field of medicine away from the
pre-scientific theorizing and more towards building the field on a
foundation of actual findings.
This pioneering work of Morgagnis led to a new way of practicing
medicine: Correlate the signs and symptoms with the patient's pathology
on autopsy. To do an autopsy was the cutting edge (oops, excuse the
double meaning there), then, in the top medical schools in the late
18th and early 19th century.
Note also that there was a
significant gradient between the thinking at the top medical schools
where new ideas were being entertained and the vast bulk of practice
which was still mired in theories that are now no longer considered
valid—and indeed, thought of as rather quaint, such as the doctrine
that disease is caused by an imbalance of the four humors, of the value
of bleeding, sweating, salivating, getting the poisons out, and so
forth. Indeed, such theories and practices continued well into the 19th
century and in some folk traditions, even into the 20th century. The
point, though, is to realize that autopsies became cutting edge of
science, like people today who are excited about the internet and the
hubble telescope. At the big hospitals, the whole idea of a more
systematic, up-to-date, modern, scientific approach was the big thing.
Doctors used to be all frippery and never got their hands dirty.
was just for surgeons, who were low status. While to the aristocracy and
near aristocracy, doctors were tradesmen, yet within those fields,
there was a hierarchy of doctors above surgeons and apothecaries... in
the 18th and early 19th centuries. (Actually, the field of surgery went
way up in status in the late 19th century!)
So at the turn of the 1800s, the modern physician did get in there and
get blood and pus on his coat. It was a badge of honor, a way to say,
“I am involved. I am engaged! I am wrestling with science. I am modern,
The problem was that everything was filthy. Fecal contamination was
everywhere in the streets, you could smell a city miles before you came
into its outskirts, there wasn’t much money for fuel to boil water,
either for drinking much less bathing. Bathing was just coming back
into fashion, because at the beginning of the 18th century hardly
anyone bathed with any degree of frequency. It was also a religious
thing, a sign of pridefulness, to bathe. And it was an invitation to
sexuality. Whatever—the history of bathing is a whole other thing.
It should be noted that the movement to clean up the sewage
the purify water was also beginning in that era. A newspaper cartoon
tried to call people’s attention to this---the picture on the left is
called "monster soup," referring to what a microscope might see on
looking at the Thames river.
There’s a new book in the library—I had them order it—called The Big
Necessity—about a topic that many avoid—toilets, and sewers, and
sewage—read feces—purification and disposal systems, and how much all
this really necessary part of collective life, government public
health, has surprisingly frequently been avoided—it’s almost a taboo
topic! And how much this issue really needs to be addressed—and
indeed is one of the themes to be mentioned again in the last lecture.
Ignac Semmelweis and the Fight Against Childbed Fever
The brief back-story of the break from tradition beginning in the
Renaissance has been mentioned because the emergence of truly useful
knowledge must pass through currents of new theories colliding with the
weight of old theories. All this is relevant in the effort to discover
the causes of infection, and to prevent infection. This episode is set
for the 1840s, at what might possibly be the top medical
school in the world at the time: The Allegemein
Hospital in Vienna. For that time, some of the main explorers in many
beginning specialties were on the faculty. Our hero is a
not-particularly-rebellious, mainstream physician, good team player and
all that, named Ignac Semmelweis.
He was from Hungary and had a
bit of an accent—evoking the sort of assumption that his education was
second-rate that many American physicians entertain, at least
subconsciously, to their immigrant colleagues.
Microscopes were still being
developed, making new progress. Autopsies were a major technology as
the field of pathology was very avant-garde. Semmelweis had become a part of the faculty, teaching medical
students, and was concerned about a common complication of giving
birth, which was childbed fever, or puerperal fever, and was often
fatal. Why were they getting sick? What could be done to prevent this?
There were many theories!
Semmelweis noticed something that today, now that we know there are
germs, seems obvious. You can’t fool around with filthy hands. Well, in
fact, doctors did wash, but the washing was perfunctory, and their
clothes were often still contaminated with bits of pus or pus after
they had been down in the morgue doing autopsies—which, you must
remember, was the most modern thing they could or should be doing.
These guys thought they were really up-to-date, and there was a pride
in being on the cutting edge, not like their old-fashioned models,
their parents’ generation, who were technologically speaking, square,
country bumpkins, who didn’t think scientifically.
There were two units, one managed by midwives,
and one managed by doctors. And the midwives ward had many fewer cases
of childbed fever. So to make a rather long story short,
Semmelweis put two and two together—and indeed, his use of comparing
numbers of cases was one of the first examples of fairly crude
epidemiology—and with some other experiences, deciding that the docs
should not just wash, but wash in what we would now consider an
antiseptic solution, and when he was able to supervise this, wouldn’t
you know it, the infection rate went down!
A little backtracking for emotional impact.
Semmelweis’s first efforts to figure it out was to redouble the
tradition: Examining, thinking, going back and doing more autopsies,
going back and examining, and doggone it if the infections didn’t just
continue. And then a friend of
Semmelweis, while doing an autopsy of a patient who had died of
childbed fever, nicked himself with a scalpel and died of blood
poisoning, massive sepsis. Well, they did an autopsy on this friend,
too, and Semmelweis noticed that the inside of the body of the man who
died from infection from a cut on his finger while doing an autopsy had
many of the pooling of infected pus here and there, blood clots in the
blood vessels, other things that were also characteristic of what women
who had died of childbed fever had. We’d now call it a final common
pathway of massive blood infection—also called blood poisoning— and the
complications to various organs that come from this.
So Semmelweis got the idea that, aha! Childbed fever
was caused by doctors transferring what Semmelweis called cadaverous
material—who knew from germs back then? – to the
patients. Take a moment to
consider, then, how he might have felt. He himself undoubtedly caused
the death—inadvertently,—we might say today, “unintended consequences”—
of numerous young women in the prime of their lives, making the babies
orphans. Also, though, the babies often caught the infection (passing
through an infected birth canal) and they, too, died. Anyway, Semmelweis certainly was overwhelmed
with guilt, and this drove him to try to correct or even make up for
He became a bit of a fanatic on this
hand-washing business. He kept statistics, and they supported his
unfolding theory. Semmelweis still didn’t know about microbes, germs.
He did get the sense of contagion by cadaverous material. Later on he
got that a patient could get infected by the presence of old pus on the
clothes or sheets—and they didn’t do much laundry there—and even from
someone with a bad open infection being in the same room. Semmelweis was in charge of
a unit and insisted that the young men, medical students, nurses,
anyone who was to examine a woman before or after giving birth, would
have to wash in a chlorinated lime solution. To the extent that he
could supervise them, the rate of infection dropped. And on other units
they stayed high, and if he had support and the students obeyed, the
rate went down, or if the med students took a month off, the rate went
down, and when they got back to their bad habits, the rate went up. So
he became increasingly convinced and tried to convince others. Some he
did, and many he didn’t. It’s quite a story.
Oliver Wendell Holmes, Senior
Unbeknownst to Semmelweis, there was another doctor, at Harvard, in Boston.
Quite reputable, Dr. Oliver Wendell Holmes, Senior, also was
having a similar insight and getting similar back pressure. Note that
there were two of them, both famous in the 19th century, the father and
his son.. The son, OWH, Jr. was a famous
supreme court justice, doing his thing in the latter part of the 19th
century. The father, OWH Sr. was not only a physician, but historically
better known as a poet and essayist—that’s where I first encountered
the name: He wrote several poems, like Old Ironsides, and other stuff I
read in high school English when they talked about American Literature.
But that was a sideline! Holmes was mainly a physician, and
of his main things was the campaign to promote hygiene—that’s another
word for preventive medicine—by cleanliness, hand-washing, etc.
About the resistance to new ideas: A little psychology here, since
that’s my specialty: If you mean well, and have noble intentions, it’s
hard to consider that what you do is counter-productive, or has
unintended consequences, or is radically foolish. That’s been a problem
throughout history and has been quite recently played out on the
national and international political scene. It’s even harder to hear
that you might be the problem when you’re bustin’ your butt to be the
best doctor in the world, at the best hospital, using the most modern
Also, both Holmes and Semmelweis were mainstream and mildly
established, but also on the young side, so their authority wasn't
great in terms of seniority; and, furthermore, there
were also a variety of plausible alternative explanations, so it might
be explainable why other physicians might wonder why they were supposed
to wash in an annoying and somewhat harsh antiseptic solution that was
both bothersome and time-consuming. Then, as now, being "busy"
generated a subtle sense of entitlement as an excuse for haste and
Moreover, so much of life, equipment, and so forth was dirty, stinking,
filthy. This was a charitable hospital, after all. There wasn’t much
or many resources for cleanliness. Nurses back then were paid a
pittance---the economic angle---and were far from being the
professionals they are today. Indeed, their dirty work put them below
that of washer-women. With the exception of the cadre of women
recruited by Florence Nightingale, nurses were often ignorant,
not infrequently alcoholic, and not above some on-the-side prostitution
if it would make some money. The only reason anyone went to the
hospital is that things were even more wretched at home with kids’
demands and other kinds of dirtiness there. Even a little help was
better than nothing.
This was an era of urbanization, of people moving from the country to
the city, of child labor, of sunless cities, and rickets—the vitamin D
deficiency that comes with a lack of sunlight—was very common (I’ll
talk about vitamin and nutritional deficiencies in the 5th lecture.).
Bones were distorted, and that included women’s pelvises, meaning that
there were all sorts of difficult birth problems. Forceps deliveries
were common, and these instruments entered the edge of the opening
womb—and before sterilization became routine—that would take another—if
you can believe this—fifty years or more—then it was like rubbing dirt
into an open wound.
Another thing about wounds and infection and the theories of infection.
If you get a cut, there’s a fair chance it’ll get infected; but often
infections were by not-terribly-pathogenic germs, like staphylococcus
alba, leading to a kind of white pus. If you can believe it, doctors
considered this good pus, they called it laudable pus. It was the kind
of infection that was slow to heal, but heal it did. There were other
germs that got in wounds that were bad, led to gangrene. And if these
bad germs were in certain tissues with a rich blood supply, they you
got septicemia and died, more often than not.
Childbed fever, puerperal fever, was one of the bad diseases. An
infection in the lining of the uterus, called endometritis, went all
over. That itself slowed down the understanding of the problem.
Sometimes it went right into the bloodstream, sometimes the infection
leaked into the abdomen, giving peritonitis. Sometimes infectious blood
clots would form and go to the lungs—the point is that when things went
wrong, the condition could take on a variety of mid-to-end-point
symptoms and signs—but the high fever, the shaking chills, the pain,
all was bad news.
The thing to emphasize is that the best docs when your great great
great grandmother lived didn’t have a clue. They had fifteen to thirty
competing explanations. One of those was contagion, but that itself
wasn’t at all clear. A big cause was obviously the miasma, the gassy
exudates of under-ventilated rooms, the smells of sewage and feces, and
so forth. The treatment was fresh air, if any could be found. The
problem is that it missed the point—and we’ll talk more about this
So back to Semmelweis: It became painfully clear that there was a tight
correlation between visits from the doctors and patients dying. Can you
imagine the guilt he must have felt when he realized that some of the
stuff he had been doing had been making patients worse?
In my (Adam's) personal background, I, too, became more aware of
possibly having contributed to secondary or nosocomial infection in
some of my patients, and felt more than a few pangs myself when,
several years— decades, really—after my internship at Los Angeles
County Hospital, that we doctors —this would be back around 1964---were
practicing a level of not-half-tight-enough cleanliness, compared to
what infection control standards of the late 1970s and 1980s became.
But we were so idealistic, and we really tried! And we were ten
times as clean as anything Semmelweiss wanted—but we now know enough to
know that even more is needed.
Semmelweis' story is involved, full of political ups and
downs. He made some real allies, but he also made many enemies—in
contrast to Joseph Lister, about whom we’ll here in a moment. For one
thing, he tended to attack the intentions, the honor, if you will, of
those who didn’t buy into his theory. Remember, microscopes had just
been developed and not a lot of people had seen germs.
An interesting and tragic side point. There were some new microscopists
at that Viennese medical center, and Semmelweis could have inspected
the purulent discharge from the vagina—the result of the infection of
the uterine walls—and seen the bacteria, maybe. It could have
strengthened his case. But he relied on his numbers, and others found
other ways to explain these. Semmelweis also failed to write up his
findings for many years, and some allies had to summarize—and they
didn’t present the case optimally.
Another factor: This was now 1848, and the liberal revolution of 1848
swept Europe, Semmelweiss chose the liberal side, his bosses were
conservative, and as the Austro-Hungarian empire and other
authoritarian institutions reasserted their power—the revolution
weakened—Semmelweiss was demoted.
In spite of having a number of influential allies, he was too sensitive
to defeat, and responded to the pressure by suddenly and without
warning just leaving town, leaving Vienna, and returned to Budapest.
The story goes downhill from here: Semmelweis gets mentally weird. The
history sounds like tertiary syphilis—a not uncommon problem in that
era—you have a fling with a prostitute as a young man and your goose
may well be cooked. Or your brain, which deteriorates, into a condition
known as General Paresis or Paralysis of the Insane. They didn’t know
what caused it, it constituted maybe a third or more of the mentally
ill in hospitals near the end of the century—this history of syphilis
is a whole ‘nother lecture. But such people do often go through phases
of mania, depression, and paranoia, which he did. Semmelweis did
finally write, but it had that writing contaminated by mania and
dementia, full of redundancies, attacks, self-glorification, and in
short, no one read it, or those that did found the format such a
turn-off that the substance was discounted. This is an important
historical lesson. I’ve known of others with good ideas who presented
them orally or in writing so poorly that the valid parts couldn’t be
Anyway, Semmelweis ended up being hospitalized and the attendants at
that time around 1865 often beat patients up to quiet them. If they
were uppity, they beat them more, and from the evidence, Semmelweis
died from complications of violence a couple years after being
hospitalized. Alas, he was only in his mid-40s.
Later on Semmelweiss was recognized as being prescient, right, and
honored posthumously. But to appreciate his work, several other
discoveries had to happen, so that other objections to this
inconvenient truth for that time might be considered. (Inconvenient,
because generating a clean, much less aseptic context, is, frankly,
difficult and expensive! We’ll talk more about that later on.)
Now let’s talk about another story that overlaps this. Louis Pasteur in
France was just beginning to explore some of the problems that would
result in an understanding of the existence and action of microbes,
Some highlights of Pasteur's life:
(1) The discovery that organic chemicals
could have isomers, forms that were either in a figurative way of
speaking, either right- or left-“handed.”
(2) While the process of fermentation was
known for millennia, Pasteur discovered that the ferment consisted of
living micro-organisms! As a corollary, fermentation wouldn’t work
unless the organisms were alive—and they also had to be the right
organisms for the job!
(3) There is no such thing as “spontaneous
generation.” Life and also organic decay required the action of living
organisms (or eggs)
(Demonstrated bacteria in air, as with equipment in the picture above---1860.
(4) Disease in silkworm (1865), wine, and people could be caused by micro-organisms (i.e., germs).
(5) Discovered microscopically (with Sternberg) various bacteria! (1877-1880)
(6) Germs can be weakened so they don’t cause
disease, and can be then used as a kind of vaccine to help a larger
organism resist the disease that would otherwise be caused by that germ
(e.g., anthrax, 1881; rabies, 1885).
I’ll talk about the last item---vaccines---in next week’s lecture, about the
history of immunology.
The point to be made here is that item number
one gave Pasteur a bit of a reputation, so that he was hired to consult
on some problems of why a factory that turned sugar-beets into alcohol
was going sour. From this he discovered pasteurization. The point is
that the wrong kind of micro-organisms could change the nature of the
fermentation from what is desired to what is undesirable.
Part of the delay in this discovery was that before the improvements
made to microscopy in the 1870s, this tool hadn’t much been applied
to medicine. Some of this involved staining technology. Other progress
was made in the still new field of microscopic anatomy called
"histology." If you were a scientist then, if it didn't occur to you to
look specifically for germs, you would not be likely to perceive them
or appreciate their meaning. Even if you did see them,
without that appreciation, you’d just think these dots and dashes were
contamination, background stuff.
Another factor slowing down Pasteur's ideas' being more widely accepted was the fact that Pasteur wasn’t even a doctor! He was a
chemist. Later on, physicians didn’t lend his findings a lot of credit
because he wasn’t even a doctor. Ho ho. In fact, many significant
discoveries in medicine were anticipated or first made by
When he was in his early 30s, Pasteur was asked to consult about why
some factories that converted beet-sugar into alcohol were failing
because the resulting material was sour and smelly. We’re talking about
the process of fermentation, here.
The Problem of Germs
Just to note, for the record, others had talked about the possibilities
of contagion and the communicability of diseases.
There were clues in
the behavior of the new disease of Syphilis, probably imported from the
New World—the Western Hemisphere— by Columbus’ sailors, in return for
our sending smallpox and other epidemic diseases over there from
Europe. Girolamo Fracastoro wrote about the idea of contagion in a
treatise that used the term Syphilis for the first time, instead of
calling it The French Disease—because for the first fifty years after
Columbus, folks in France were calling it the Spanish Disease, or the
Italian Disease. At that time, there were big pock marks formed—it’s
become more mild in the last two or three hundred years— and it was
also called the Great Pox—in contrast to the Small Pox about which
we’ll speak next time.
Historical research has found reports in the previous centuries
suggesting the possibility of something like germs, but they didn’t
know what to make of these patterns. The microscope hadn’t developed
strong enough resolution back then to see bacteria, and so forth. So
ideas would blossom and then be overlooked.
A related problem in all this that had been around for centuries is the
origins of life, and through various experiments, around 1859, Pasteur
showed that it didn’t just happen, there had to be contamination. Soon
after this, in medicine, in another country in Europe, another
researcher demonstrated something similar: Cells had been discovered as
universal components of plants and animals, but they didn’t just
crystallize out of the formless background gunk; rather they were
produced by parent cells. All this happened around 1860. Remember,
folks didn’t hear about each others’ results all that quickly, if at
Pasteur continued to explore the idea that micro-organisms could
cause disease, not just by souring wine, but in animals and as a source
A round 1865 he did research on Silkworms. While Pasteur
was made into a national hero by 1880, in the years before that he was
not infrequently challenged and this led him to further experiments to
make his points.
A couple of interesting points. He had a significant stroke in mid-life
and yet kept going, with an arm and a leg significantly weakened. His
findings weren’t readily accepted by physicians because he wasn’t a
physician, just a chemist. By mid-life, Pasteur was also beginning to
work toward the establishment of research institutes, to get
governmental funds allocated, and the like—and in a sense, this was
also a pioneering effort that was one step removed from the actual
It addressed the infrastructure that I’ve
Let’s turn to another major pioneer: Joseph Lister—from whom you get
the name Listerine.
Lister was a mainline doctor in Scotland—and the
University of Edinburgh was at the time another major center of
research and discovery. To the right are photos, first, of him and his
wife, Agnes, around 1856. It should be noted that she was of great help
to him in his many endeavors! Later, when older and much honored, in
the 1890s, he was then Lord Lister, given a peerage!
Lister was disturbed by the prevalence and not
infrequent fatal results of surgery and major injury, all due to
infection. He didn’t know about germs. (Interestingly, he was the son
of another physician who had made some substantial contributions to the
improvement of the microscope around 1830.) Still, microscopes and
technology weren't able to demonstrate germs clearly before around
1870. But also around 1865, he did
get the idea that there was infection in the air---and had heard of
Pasteur's experiments --- and instituted the
practice of spraying the area of surgery with the antiseptic, carbolic
acid. Relative cleanliness of the wounds, putting on carbolic
acid-soaked dressings, such efforts were rewarded.
Lister didn’t attack his enemies, but rather built his case, gradually,
with statistics, written papers, presentations at professional
conferences. He did in time learn about Pasteur’s work and acknowledged
that it helped his efforts, and in the long run was recognized and even
elevated into the peerage—made a Lord!
So Lister's techniques were implemented. Here are some photos of early
surgeries using different instruments for the spray of the carbolic
acid: On the right you can see the concomitant administration of
This technology gave rise to the manufacture of more refined machines:
Gradual Dissemination of Antiseptic Awareness
It took decades before sufficient mainline professors accepted and
began to implement antiseptic concepts, the awareness of the existence
of germs and how they cause infections, and how they can be avoided.
Here's a famous painting by the artist Thomas Eakens, titled the Gross
Clinic---portraying a leader in the field---but the idea of cleanliness
had not yet penetrated to this midwestern American region with a
high-ranking medical faculty. But this level of non-antisepsis also had
a relatively higher rate of secondary infection.
Robert Koch, Louis Pasteur, and Bacteriology
Microscopy finally was developed enough, along with staining techniques, to see germs:
But advances were happening. Better microscopy, better staining, and people started being able to see germs.
By 1875 the idea of germs was becoming more clear, and further changes
in microscopy, the use of oil-immersion lens, and staining, all made it
more possible to see the little bugs. Koch’s contributions here were
significant, but for our purposes a full description would elaborate
this story in some other directions—as fractal branching can do. So,
for the purposes of this lecture, we’ll stay with the following course
of seeing what it all had to do with surgery.
If there are germs, why just use anti-sepsis to try to kill ‘em in the air and on the
ground? The next step, then, was a-sepsis, the idea being keep germs away from the wound to begin with. completely?
Dr. Ernst Von Bergmann in Berlin developed the idea of, first, stronger
chemical antiseptic sterilization of instruments (1877), and then in
1880, steam heat for sterilization. His photo, left, and also an
"autoclave" (though this one shown is a more modern version, from the
There was a coming together of several technologies here. Robert Koch (picture to right)
was another pioneer of bacteriology. Beginning in the 1870s, among
other things, he worked out was the technique of assessing how many
were on a specimen or swab—ten, a hundred, a million? And this
allowed a way of getting feedback to how successful efforts at cleaning
things—drapes, sheets, clothes, and especially instruments—were.
Suffice it to say, ordinary cleaning doesn’t do it. So the next phase
went through one step after another in order to make things more and
more clean, and, indeed, sterile.
Changing the Instruments
Surgical instruments used to be made with wooden handles, and for the fancy
specialist, ivory handles. These were further engraved for better
handling. But these were also impossible to sterilize, because germs could "hide" in their
Another refinement was needed----this need to bring diverse
technologies together is part of this larger story— and that was the
manufacture of all metal tools that could be sterilized.
|These in 1840s are impossible to sterilize.
|These made in the 1870s can be autoclaved, steam sterilized.
Around 1880, other aseptic techniques were applied: In addition to
sterilization of the instruments, a shift away from wearing street
clothes was instituted and spread from Europe to the United States.
(Before the 20th century, Western Europe was generally viewed as
leading the USA in medical advances.) Sheets, drapes, towels,
sponges---all were to be sterilized. The skin was to be meticulously
cleansed. Later, antiseptics were applied to the skin, also. Routines
for the doctors and surgical nurses also carefully washing---scrubbing,
really, and it was called "scrubbing up"---were instituted.
In the following pictures, some progress can be seen between the 1880s and 1970s:
|Surgery at the University of Pennsylvania, 1890s.
| Dr. Billroth in Europe, 1890s.
The open operating rooms were closed. There was a new goal of making them easier to clean meticulously.
Here's an operating room in the 1820s, before any thought of germs and
antisepsis. And here's one after 1900, with asepsis kept in mind.
Notice that the doctors had begun to wear special, clean suits---white
instead of the more modern green that came to be used after the
1920s---. The green special surgical outfits came to be called "scrubs"
because doctors (and nurses) would change into them, including
coverings for shoes, and then put gowns over them!
Another shift from around 1900 to 1920 was the adoption of rubber gloves and face masks, plus better covering of the hair.
An interesting anecdote about rubber gloves. Halstead, above
left, was asked by his chief nurse, Caroline Hampton, what could help
the problem of the antiseptic washing solution irritating her hands.
Halstead as chief of surgery had a mold made of her hands and rubber
gloves ordered specially for her. Later, he found the idea was
good---it extended the whole concept of asepsis another step. By the
way, the nurse went on to marry the chief surgeon. Also, it used to be
wore gloves so as not to catch a disease, but then it changed over so
that doctors wouldn’t unintentionally give a disease, contaminate a
Moving the story up to 1970s and beyond, this picture of a surgery, in which the air itself is being sterilized:
The key to infection, then, is---of course---germs, about which little
was known less than a hundred and fifty years ago. There has been a
good deal of attention given to infection control in the first quarter
of this century, but progress was slackened a bit in the anti-biotic
era of the 1940s through the 1960s. Following that, gradually there
came to be a heightened awareness of antibiotic resistance in an
increasing number of cases, of sub-types of germs!
So consider then a couple of words for your vocabulary:
Iatro-genic: Iatro is Greek for physician. I am not a student of the
mind–a psych-ologist, but rather a psych-iatrist—an iatros, a physician
who has specialized in disorders of the mind. I integrate a good deal
of psychology in my learning, but that’s not my official field.
Iatro- .. Then genic is like genesis, the beginning, cause. So an
Iatro-genic disease is when you’re sick because of what the doctor did.
Nosocomial: Nosocom is greek for hospital, and it’s a disease you catch because
others are there with certain germs—the kid in the next bed with a
strep throat... that kind of thing.
It’s not the same as "iatrogenic" in meaning, though the two words in fact overlap a bit. .
There’s been a great deal of attention given to nosocomial infections,
and much more especially now that increasing numbers of cases of
anti-biotic resistant germs are cropping up. So a lot of the increase
in medical costs is going into infection control, into making hospitals
less likely to spread germs. Now if we can get doctors to wash their
hands—really, that continues to be a big problem, and I suggest that
you bug your docs by asking them to wash where you can see them wash
before you let them touch you. Really wash, too. Assume they’ve just
been feeling around on some infected wound just before entering your
waiting room. Blame me.
I’m open to questions.